Advances in critical care/emergency medicine 2013.

O f the many publications in this field, the ones discussed hereunder seem to be most relevant for clinical practice. Intravenous thrombolysis with tissue plasminogen activa-tor (tPA) is the only therapy proven to improve outcome in ischemic stroke. Studies of intravenous thrombolysis show that response to therapy is time-dependent; the sooner the patients receive tPA, the better the chance of good outcome. 1 The required brain imaging before tPA administration delays the initiation of therapy because it necessitates patient transport. In the Pre-Hospital Acute Neurological Treatment and Optimization of Medical Care in Stroke (PHANTOMS) pilot study, Weber et al 2 attempt to speed up stroke treatment by administering tPA before hospital arrival. When patients with presumed stroke contacted the emergency medical system, a stroke emergency mobile unit equipped with a CT scanner was dispatched. Brain imaging was performed at the scene, enabling tPA administration in the stroke emergency mobile unit. For patients in stroke emergency mobile unit, the median time between emergency call and initiation of tPA was 58 minutes (5–63); this time was 92 minutes (79–112) in a group of historic controls. The PHANTOMS study was a nonran-domized study performed in urban Germany. A randomized controlled study performed in a more rural region of Germany showed a similar relative decrease in the time to tPA treatment among patients treated in a CT-equipped mobile stroke unit compared with those treated in the emergency room. 3 These studies show that CT-equipped mobile stroke units decrease the time to tPA administration, which could translate into significant clinical benefit. Hyperglycemia is associated with worse stroke outcome, but there is no evidence that strict glucose control improves outcome. In a proof-of-concept study to determine if aggressive glucose management could attenuate infarct growth, patients with carotid territory strokes were randomized to intensive insulin therapy (N=87) or standard (subcutane-ous) insulin therapy (N=89) <6 hours after symptom onset. 4 In the intensive insulin therapy group, insulin was administered as a continuous infusion with a goal glucose <7 mmol/L (<126 mg/dL) for a duration of 24 hours. MR images were obtained <5 hours after onset (before randomization) and again after cessation of therapy. Although the intensive insulin therapy regimen improved glucose control, it was associated with increased infarct growth. The intensive insulin therapy regimen also led to an increase in hypoglycemia episodes. Clinical outcomes were similar between the treatment groups. The ongoing Stroke Hyperglycemia Insulin Network Effort (SHINE) …